AIDS Behav DOI 10.1007/s10461-015-1016-z
ORIGINAL PAPER
Sexual Violence Against Men Who Have Sex with Men in Brazil: A Respondent-Driven Sampling Survey Meritxell Sabido´ • Ligia Regina Franco Sansigolo Kerr • Rosa Salani Mota • Adele Schwartz Benzaken • Adriana de A. Pinho • Mark D. C. Guimaraes • Ines Dourado • Edgar Merchan-Hamman • Carl Kendall
Ó Springer Science+Business Media New York 2015
Abstract We estimated the prevalence of sexual violence (SV) experience among men who have sex with men (MSM) in Brazil and identified its associated risk factors. We recruited 3859 MSM through respondent driven sampling. A multivariable hierarchical analysis was performed using an ecological model. The prevalence of having ever experienced SV was 15.9 % (95 % confidence interval [CI] 14.7–17.1). SV experience was independently associated with discrimination due to sexual orientation (odds ratio [OR] 3.05; 95 % CI 2.10–4.42), prior HIV testing (OR 1.81; 95 % CI 1.25–2.63), B14 years at first sex (OR 1.86; 95 % CI 1.28–2.71), first sex with a man (OR 1.89; 95 % CI 1.28–2.79), presenting STI symptoms (last year) (OR 1.66; 95 % CI 1.12–2.47), and having suicidal ideas (last
6 months) (OR 2.08; 95 % CI 1.30–3.35). The high levels of SV against MSM in Brazil place them at a markedly higher risk of SV than the general population. Homophobic prejudice is the strongest determinant of SV and urgently needs to be included at the forefront of the national response to SV.
M. Sabido´ (&) Fundac¸a˜o de Medicina Tropical Doutor Heitor Vieira Dourado (FMT-HVD), Avenida Pedro Teixeira 25, Manaus, AM CEP: 69040-000, Brazil e-mail: [email protected]
A. de A. Pinho Escola Nacional de Sau´de Pu´blica, Fundac¸a˜o Oswaldo Cruz (FIOCRUZ), Rio De Janeiro, Brazil
M. Sabido´ TransLab. Department of Medical Sciences, Universitat de Girona, Girona, Catalunya, Spain L. R. F. S. Kerr Departamento de Sau´de Comunita´ria, Universidade Federal do Ceara´, Fortaleza, Brazil R. S. Mota Departamento de Estatı´stica e Matema´tica Aplicada, Universidade Federal do Ceara´, Fortaleza, Brazil A. S. Benzaken Fundac¸a˜o Alfredo da Mata, Manaus, Brazil
Resumen Se estimo´ la prevalencia de haber experimentado violencia sexual (VS) entre hombres que tienen sexo con hombres (HSH) en Brasil y se identifico´ sus factores de riesgo. Se recluto´ 3859 HSH mediante respondent driven sampling. Se realizo´ un ana´lisis multivariado hiera´rquico usando un modelo ecolo´gico. La prevalencia de
M. D. C. Guimaraes Departamento de Medicina Preventiva e Social, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil I. Dourado Instituto de Sau´de Coletiva, Universidade Federal da Bahia, Sa˜o Salvador, Brazil E. Merchan-Hamman Departamento de Sau´de Coletiva, Universidade de Brası´lia, Brası´lia, Brazil C. Kendall Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
A. S. Benzaken Departamento de DST, Aids e Hepatites Virais, Secretaria de Vigilaˆncia em Sau´de, Ministe´rio da Sau´de, Brası´lia, Brazil
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experiencia de VS alguna vez fue 15.9 % (Intervalo de confianza [IC] 95 % 14.7–17.1). Los factores asociados independientemente con haber sufrido VS alguna vez fueron discriminacio´n debida a orientacio´n sexual (odds ratio [OR] 3.05; 95 % CI 2.10–4.42), haber realizado la prueba del VIH (OR 1.81; 95 % CI 1.25–2.63), B14 an˜os de edad en la primera relacio´n sexual (OR 1.86; 95 % CI 1.28–2.71), primera relacio´n sexual con un hombre (OR 1.89; 95 % CI 1.28–2.79), presentar sı´ntomas de ITS durante el u´ltimo an˜o (OR 1.66; 95 % CI 1.12–2.47), y tener ideas suicidas durante los u´ltimos 6 meses (OR 2.08; 95 % CI 1.30–3.35). Los altos niveles de VS contra los HSH en Brasil situ´an este grupo ante un riesgo de VS superior que la poblacio´n general. La homofobia es el determinante ma´s importante y debe de encabezar urgentemente la respuesta nacional ante la VS. Keywords Sexual violence Risk factors MSM Respondent-driven sampling Brazil
Introduction Although the vulnerability of MSM to violence has been demonstrated [1], sexual violence (SV) against MSM is an unrecognised public health priority. As a consequence of SV, men can experience physical and mental symptoms, including post-traumatic stress symptoms, depression, and suicide [2]. Limited studies have suggested an increased risk of HIV infection among MSM experiencing SV [3] while other studies did not establish an association between these factors [4–6]. MSM more frequently experience extreme forms of SV, such as rape, than non-MSM [4]. In some African countries, up to 10 % of MSM consider violence as the most important threat to their personal health, constituting a greater concern than HIV/AIDS [5]. SV involving MSM has received little attention, with few studies conducted in low and middle-income countries [4, 7–10] but systematically showing high levels of SV victimization. The hidden and stigmatized nature of MSM populations in much of the world [11], and the difficulty of measuring socially constrained and stigmatized behaviors [12], presents challenges for research on SV among MSM and results in an underestimation of the extent of SV in this group [1]. Nevertheless, MSM have consistently reported high levels of SV experience at some point in their lives. Up to 10 % of Hispanic MSM in the USA [13] and 14 % of Puerto Rican gay men [9] reported having experienced intimate partner SV. In both India [8] and Thailand [10], convenience samples including a high proportion of transgender and male sex workers showed male-on-male SV rates of 18 %. In South Africa, a respondent driven
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sampling (RDS) study found that 16 % of MSM experienced male-on-male SV [4], while in Brazil, 20 % of urban MSM reported experiencing intimate partner SV [14]. In addition, reported rates of male-on-male SV victimization have been higher than among non-MSM [4, 14]. Our understanding of the factors associated with SV against MSM is far from complete. In a six country survey that included Brazilian MSM, experience of homophobia were shown to increase the risk of reporting intimate partner SV [15]. In South Africa, black MSM, those 25 years or older, and those who had fathered a child showed an increased risk of SV victimization [4]. Some risk behaviors have also been associated with SV experience, specifically an increased number of male sexual partners, drug use, and buying sex [10, 16]. Because SV is a complex and multifaceted problem, we used the ecological model to examine it [17]. This theoretical framework discusses 4 levels of risk: socio-demographic, community, relationship, and individual. The model provides a framework for understanding the influence of biological, psychological, social, cultural, and economic factors and their interplay (Fig. 1). The aim of this study was to estimate the prevalence of SV in a national sample of MSM in Brazil and to examine the societal, community, relationship, and individual factors associated with SV experience. Understanding the extent of SV among MSM, as well as its context, will contribute to implementing prevention and care interventions for this group.
Methods Study Design We conducted a cross-sectional study of MSM in 10 Brazilian cities in 2008–2009 [18]. The objectives of the national study were to estimate the prevalence of HIV and syphilis and to identify their associated risk factors. The pooled HIV prevalence was estimated at 14.2 % (95 % CI 12.1–16.6) [18]. The cities were chosen by the Department of STD, AIDS and Viral Hepatitis of the Brazilian Ministry of Health based on their regional, socioeconomic, and cultural diversity. The cities included were Manaus, Recife, Salvador, Campo Grande, Brası´lia, Curitiba, Itajaı´, Santos, Belo Horizonte, and Rio de Janeiro. The study was approved by the National Ethics Research Committee (CONEP # 14494). Study Population and Sampling Method Eligible participants were 18 years or older, residents of the selected cities, had sex with a man or a transgender
AIDS Behav
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ORIGINAL PAPER
Sexual Violence Against Men Who Have Sex with Men in Brazil: A Respondent-Driven Sampling Survey Meritxell Sabido´ • Ligia Regina Franco Sansigolo Kerr • Rosa Salani Mota • Adele Schwartz Benzaken • Adriana de A. Pinho • Mark D. C. Guimaraes • Ines Dourado • Edgar Merchan-Hamman • Carl Kendall
Ó Springer Science+Business Media New York 2015
Abstract We estimated the prevalence of sexual violence (SV) experience among men who have sex with men (MSM) in Brazil and identified its associated risk factors. We recruited 3859 MSM through respondent driven sampling. A multivariable hierarchical analysis was performed using an ecological model. The prevalence of having ever experienced SV was 15.9 % (95 % confidence interval [CI] 14.7–17.1). SV experience was independently associated with discrimination due to sexual orientation (odds ratio [OR] 3.05; 95 % CI 2.10–4.42), prior HIV testing (OR 1.81; 95 % CI 1.25–2.63), B14 years at first sex (OR 1.86; 95 % CI 1.28–2.71), first sex with a man (OR 1.89; 95 % CI 1.28–2.79), presenting STI symptoms (last year) (OR 1.66; 95 % CI 1.12–2.47), and having suicidal ideas (last
6 months) (OR 2.08; 95 % CI 1.30–3.35). The high levels of SV against MSM in Brazil place them at a markedly higher risk of SV than the general population. Homophobic prejudice is the strongest determinant of SV and urgently needs to be included at the forefront of the national response to SV.
M. Sabido´ (&) Fundac¸a˜o de Medicina Tropical Doutor Heitor Vieira Dourado (FMT-HVD), Avenida Pedro Teixeira 25, Manaus, AM CEP: 69040-000, Brazil e-mail: [email protected]
A. de A. Pinho Escola Nacional de Sau´de Pu´blica, Fundac¸a˜o Oswaldo Cruz (FIOCRUZ), Rio De Janeiro, Brazil
M. Sabido´ TransLab. Department of Medical Sciences, Universitat de Girona, Girona, Catalunya, Spain L. R. F. S. Kerr Departamento de Sau´de Comunita´ria, Universidade Federal do Ceara´, Fortaleza, Brazil R. S. Mota Departamento de Estatı´stica e Matema´tica Aplicada, Universidade Federal do Ceara´, Fortaleza, Brazil A. S. Benzaken Fundac¸a˜o Alfredo da Mata, Manaus, Brazil
Resumen Se estimo´ la prevalencia de haber experimentado violencia sexual (VS) entre hombres que tienen sexo con hombres (HSH) en Brasil y se identifico´ sus factores de riesgo. Se recluto´ 3859 HSH mediante respondent driven sampling. Se realizo´ un ana´lisis multivariado hiera´rquico usando un modelo ecolo´gico. La prevalencia de
M. D. C. Guimaraes Departamento de Medicina Preventiva e Social, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil I. Dourado Instituto de Sau´de Coletiva, Universidade Federal da Bahia, Sa˜o Salvador, Brazil E. Merchan-Hamman Departamento de Sau´de Coletiva, Universidade de Brası´lia, Brası´lia, Brazil C. Kendall Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
A. S. Benzaken Departamento de DST, Aids e Hepatites Virais, Secretaria de Vigilaˆncia em Sau´de, Ministe´rio da Sau´de, Brası´lia, Brazil
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experiencia de VS alguna vez fue 15.9 % (Intervalo de confianza [IC] 95 % 14.7–17.1). Los factores asociados independientemente con haber sufrido VS alguna vez fueron discriminacio´n debida a orientacio´n sexual (odds ratio [OR] 3.05; 95 % CI 2.10–4.42), haber realizado la prueba del VIH (OR 1.81; 95 % CI 1.25–2.63), B14 an˜os de edad en la primera relacio´n sexual (OR 1.86; 95 % CI 1.28–2.71), primera relacio´n sexual con un hombre (OR 1.89; 95 % CI 1.28–2.79), presentar sı´ntomas de ITS durante el u´ltimo an˜o (OR 1.66; 95 % CI 1.12–2.47), y tener ideas suicidas durante los u´ltimos 6 meses (OR 2.08; 95 % CI 1.30–3.35). Los altos niveles de VS contra los HSH en Brasil situ´an este grupo ante un riesgo de VS superior que la poblacio´n general. La homofobia es el determinante ma´s importante y debe de encabezar urgentemente la respuesta nacional ante la VS. Keywords Sexual violence Risk factors MSM Respondent-driven sampling Brazil
Introduction Although the vulnerability of MSM to violence has been demonstrated [1], sexual violence (SV) against MSM is an unrecognised public health priority. As a consequence of SV, men can experience physical and mental symptoms, including post-traumatic stress symptoms, depression, and suicide [2]. Limited studies have suggested an increased risk of HIV infection among MSM experiencing SV [3] while other studies did not establish an association between these factors [4–6]. MSM more frequently experience extreme forms of SV, such as rape, than non-MSM [4]. In some African countries, up to 10 % of MSM consider violence as the most important threat to their personal health, constituting a greater concern than HIV/AIDS [5]. SV involving MSM has received little attention, with few studies conducted in low and middle-income countries [4, 7–10] but systematically showing high levels of SV victimization. The hidden and stigmatized nature of MSM populations in much of the world [11], and the difficulty of measuring socially constrained and stigmatized behaviors [12], presents challenges for research on SV among MSM and results in an underestimation of the extent of SV in this group [1]. Nevertheless, MSM have consistently reported high levels of SV experience at some point in their lives. Up to 10 % of Hispanic MSM in the USA [13] and 14 % of Puerto Rican gay men [9] reported having experienced intimate partner SV. In both India [8] and Thailand [10], convenience samples including a high proportion of transgender and male sex workers showed male-on-male SV rates of 18 %. In South Africa, a respondent driven
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sampling (RDS) study found that 16 % of MSM experienced male-on-male SV [4], while in Brazil, 20 % of urban MSM reported experiencing intimate partner SV [14]. In addition, reported rates of male-on-male SV victimization have been higher than among non-MSM [4, 14]. Our understanding of the factors associated with SV against MSM is far from complete. In a six country survey that included Brazilian MSM, experience of homophobia were shown to increase the risk of reporting intimate partner SV [15]. In South Africa, black MSM, those 25 years or older, and those who had fathered a child showed an increased risk of SV victimization [4]. Some risk behaviors have also been associated with SV experience, specifically an increased number of male sexual partners, drug use, and buying sex [10, 16]. Because SV is a complex and multifaceted problem, we used the ecological model to examine it [17]. This theoretical framework discusses 4 levels of risk: socio-demographic, community, relationship, and individual. The model provides a framework for understanding the influence of biological, psychological, social, cultural, and economic factors and their interplay (Fig. 1). The aim of this study was to estimate the prevalence of SV in a national sample of MSM in Brazil and to examine the societal, community, relationship, and individual factors associated with SV experience. Understanding the extent of SV among MSM, as well as its context, will contribute to implementing prevention and care interventions for this group.
Methods Study Design We conducted a cross-sectional study of MSM in 10 Brazilian cities in 2008–2009 [18]. The objectives of the national study were to estimate the prevalence of HIV and syphilis and to identify their associated risk factors. The pooled HIV prevalence was estimated at 14.2 % (95 % CI 12.1–16.6) [18]. The cities were chosen by the Department of STD, AIDS and Viral Hepatitis of the Brazilian Ministry of Health based on their regional, socioeconomic, and cultural diversity. The cities included were Manaus, Recife, Salvador, Campo Grande, Brası´lia, Curitiba, Itajaı´, Santos, Belo Horizonte, and Rio de Janeiro. The study was approved by the National Ethics Research Committee (CONEP # 14494). Study Population and Sampling Method Eligible participants were 18 years or older, residents of the selected cities, had sex with a man or a transgender
AIDS Behav
Level 1-LIFE EXPERIENCE IN SOCIETY Age (
